PATIENT’S PROFILE

Name: L. C. Jr.
Date of Birth: September 14, 1967
Sex: Male
Age: 43
Address: Makati City
Civil status: Married
Nationality: Filipino
Religion: Roman Catholic
Date of Admission: January 15, 2011
Chief Complaint: Abdominal pain
Admitting diagnosis: Acute Appendicitis
Attending physicians: Dr. Bagsic/ Dr. Caibiren/ Dr. Cruz
History of Present Illness:
 3 days PTC – he had abdominal pain at the right lower quadrant associated with vomiting and anorexia,
persistence prompted consult
History of Past Illness:
 This is his first admission and first operation
Family Illness History:
 Siblings have hypertension

GORDON’S FUNCTIONAL AREAS

FUNCTIONAL AREAS BEFORE DURING ANALYSIS

HOSPITALIZATION HOSPITALIZATION
HEALTH PERCEPTION / He states that health is Same as before, she He states that health is
MANAGEMENT the concept of having a states that hospital is important but he still do
healthy body. boring. some things that are
Whenever he feels sick, harmful to his body which is
he immediately consult a drinking alcohol but good
doctor thing he consult a doctor
about his health problems
NUTRITIONAL He eats only 2 or 3 times He eats 3 times a day but He needs more water to
a day but sometimes he not as much as it served, normalize her blood flow
skips meals and he drinks less water and for easily wound
He drinks water up to 2 healing
liters
ELIMINATION He states that he urinates He states that she He still has normal
5 times a day and urinates almost the same elimination pattern except
defecates once a day frequency as before but that he doesn’t defecate
defecates less frequently regularly everyday
than before
ACTIVITY/EXERCISE He considers driving the His form of exercise is just There is changes in his
tricycle everyday as his by walking when going to daily routine
exercise comfort room to urinate of
defecate
SLEEP he states that he sleeps He states that he has Difficulty in sleeping is one
early with a duration of 8 difficulty sleeping of the effects of his
hours medications
COGNITIVE He is responsive and He is responsive and Due to lack of sleep, his
participates well. cooperative but with reaction is slowed
 slowed reaction when
sleepy
PERCEPTUAL He states that he can He states that nothing had There’s no change in his
recognize easily change perception
SELF-CONCEPT His goal in life is to His goal at this point in He is focused on his
provide his family their time is to recover from his family’s wellness
daily needs especially condition and resume his
their financial needs daily routine to provide his
family’s needs
ROLE/RELATIONSHIP He is the father of his He can’t work at this He is not able to provide
family. He is the one moment due to his the daily needs of his family
working for their daily condition because he is in the
needs hospital for recovery
SEXUALITY / He is sexually active He is not having This is normal because he
REPRODUCTIVE intercourse with his wife in needs to recover and he
the hospital because of should avoid strenuous
his condition activities that could
dehiscence his wound.
STRESS TOLERANCE He states that when Same as before It seems that stress is
stressed, he just rest and decreased through
sleep sleeping
VALUES AND BELIEFS He believes that Nothing changed in his He believes that God has a
everything happens for a values and beliefs reason why he is in the
reason and he believes in hospital right now
God

PHYSICAL ASSESSMENT

Normal Findings Deviation from Rationale

Normal
Skin:
Color  Pinkish white to various None
shades of brown, consistent
Vascularity  No bleeding or bruising None
Lesions  No lesions Incision in the lower Due to Appendectomy
right quadrant
Temperature, Texture,  Warm, dry, smooth, soft, None
Moisture, and Turgor elastic (good skin turgor)
Nails:  Convex, 160 degrees between Nails are pale Inadequate oxygen or
nails and base, nails should be decreased peripherl
smooth and nail base when circulation
palpated should be firm and
nontender, not pale
Hair and Scalp:  Scalp Dry scalp The patient did not take
· Lighter in color than the Presence of dandruff a bath since admission
complexion.
· Can be moist or oily.
· No scars noted.
· Free from lice, nits and
dandruff.
· No lesions should be noted.
· No tenderness nor masses
on palpation.
 Hair
· Can be black, brown or
burgundy depending on the
race.
· Evenly distributed covers the
whole scalp (No evidences of
 Alopecia)
· Maybe thick or thin, coarse
or smooth.
· Neither brittle nor dry.

Head and Neck:

Skull  Skull None
· Generally round, with
prominences in the frontal and
occipital area.
(Normocephalic).
· No tenderness noted upon
palpation.
Face  ·    Shape maybe oval or None
rounded.
·    Face is symmetrical.
·    No involuntary muscle
movements.
·    Can move facial muscles at
will.
·    Intact cranial nerve V and
VII.
Eyes  Eyebrows Conjunctivae are pale Decreased blood
·     Symmetrical and in line circulation or decreased
with each other. oygen level
·    Maybe black, brown or
blond depending on race.
·    Evenly distributed.
 Eyes
·     Evenly placed and inline
with each other.
·    Non protruding.
·    Equal palpebral fissure.
 Eyelashes
·    Color dependent on race.
·    Evenly distributed.
·    Turned outward.
 Eyelids
o Upper eyelids cover the small
portion of the iris, cornea, and
sclera when eyes are open.
· No PTOSIS noted. (drooping
of upper eyelids).
· Meets completely when eyes
are closed.
· Symmetrical.
 Lacrimal Apparatus
o Lacrimal gland is normally non
palpable.
· No tenderness on palpation.
· No regurgitation from the
nasolacrimal duct.
 ·    Both conjunctivae are
pinkish or red in color.
·    With presence of many
minutes capillaries.
·    Moist
·    No ulcers
·    No foreign objects
 ·    Sclerae is white in color
(anicteric sclera)
 ·    No yellowish discoloration
(icteric sclera).
·    Some capillaries maybe
visible.
·    Some people may have
pigmented positions.
 ·    There should be no
irregularities on the surface.
·    Looks smooth.
·    The cornea is clear or
transparent. The features of
the iris should be fully visible
through the cornea.
·    There is a positive corneal
reflex.
 ·    The anterior chamber is
transparent.
·    No noted any visible
materials.
·    Color of the iris depends on
the person’s race (black, blue,
brown or green).
·    From the side view, the iris
should appear flat and should
not be bulging forward. There
should be NO crescent
shadow casted on the other
side when illuminated from
one side.
 ·    Pupillary size ranges from
3 – 7 mm, and are equal in
size.
·    Equally round.
·    Constrict briskly/sluggishly
when light is directed to the
eye, both directly and
consensual.
·    Pupils dilate when looking
at distant objects, and
constrict when looking at
nearer objects.
Visual Acuity  20/20 vision, clear and free of None
blurring
Ears  · The ear lobes are bean None
shaped, parallel, and
symmetrical.
· The upper connection of the
ear lobe is parallel with the
outer canthus of the eye.
· Skin is same in color as in
the complexion.
· No lesions noted on
inspection.
· The auricles are has a firm
cartilage on palpation.
· The pinna recoils when
folded.
· There is no pain or
tenderness on the palpation of
the auricles and mastoid
process.
· The ear canal has normally
 some cerumen of inspection.
· No discharges or lesions
noted at the ear canal.
· On otoscopic examination
the tympanic membrane
appears flat, translucent and
pearly gray in color.
Hearing and Balance  Sound should be heard when None
tuning fork is placed in front of
the ear canal as air
conduction< bone conduction
by 2:1 (positive rinne test)
Nose and Sinuses  Nose in the midline None
No Discharges.
No flaring of the nares.
Both nares are patent.
No bone and cartilage
deviation noted on palpation.
No tenderness noted on
palpation.
Nasal septum in the mid line
and not perforated.
 The nasal mucosa is pinkish to
red in color. (Increased
redness turbinates are typical
of allergy).
No tenderness noted on
palpation of the paranasal
sinuses.
Mouth, Oropharynx and  With visible margin Lips are dark in color Due to smoking
Lips  Symmetrical in appearance
and movement
 Pinkish in color
 No edema
Temporo-mandibular  Moves smoothly no crepitus. None
 No deviations noted
 No pain or tenderness on
palpation and jaw movement.
Gums  Pinkish in color Pale Decreased oxygen level
 No gum bleeding
 No receding gums
Teeth  28 for children and 32 for
adults.
 White to yellowish in color
 With or without dental carries
and/or dental fillings.
 With or without malocclusions.
 No halitosis.
Tongue  Pinkish with white taste buds None
on the surface.
 No lesions noted.
 No varicosities on ventral
surface.
 Frenulum is thin attaches to
the posterior 1/3 of the ventral
aspect of the tongue.
 Gag reflex is present.
 Able to move the tongue freely
and with strength.
 Surface of the tongue is rough.
 Uvula  Positioned in the mid line. None
 Pinkish to red in color.
 No swelling or lesion noted.
 Moves upward and backwards
when asked to say “ah”
Tonsils  Grade 1 – Tonsils behind the None
pillar.
 Grade 2 – Between pillar and
uvula.
 Grade 3 – Touching the uvula
 Grade 4 – In the midline.
Neck  The neck is straight. None
 No visible mass or lumps.
 Symmetrical
 No jugular venous distension
(suggestive of cardiac
congestion).
Trachea  May not be palpable. Maybe None
normally palpable in thin
clients.
 Non tender if palpable.
 Firm with smooth rounded
surface.
 Slightly movable.
 About less than 1 cm in size.
 The thyroid is initially observed
by standing in front of the
client and asking the client to
swallow. Palpation of the
thyroid can be done either by
posterior or anterior approach.
Thyroid  Normally the thyroid is non None
palpable.
 Isthmus maybe visible in a thin
neck.
 No nodules are palpable.
Thorax  The shape of the thorax in a None
normal adult is elliptical; the
anteroposterior diameter is
less than the transverse
diameter at approximately a
ratio of 1:2.
 Moves symmetrically on
breathing with no obvious
masses.
 No fail chest which is
suggestive of rib fracture.
 No chest retractions must be
noted as this may suggest
difficulty in breathing.
 No bulging at the ICS must be
noted as this may obstruction
on expiration, abnormal
masses, or cardiomegaly.
 The spine should be straight,
with slightly curvature in the
thoracic area.
 There should be no scoliosis,
kyphosis, or lordosis.
 Breathing maybe
 diaphragmatically of costally.
 Expiration is usually longer the
inspiration.
Heart  Inspection None
 Pulsation of the apical impulse
maybe visible. (this can give
us some indication of the
cardiac size).
 There should be no lift or
heaves.
 Palpation
 No, palpable pulsation over
the aortic, pulmonic, and mitral
valves.
 Apical pulsation can be felt on
palpation.
 There should be no noted
abnormal heaves, and thrills
felt over the apex.
Breast  The overlying the breast None
should be even.
 May or may not be completely
symmetrical at rest.
 The areola is rounded or oval,
with same color, (Color va,ies
form light pink to dark brown
depending on race).
 Nipples are rounded, everted,
same size and equal in color.
 No “orange peel” skin is noted
which is present in edema.
 The veins maybe visible but
not engorge and prominent.
 No obvious mass noted.
 Not fixated and moves
bilaterally when hands are
abducted over the head, or is
learning forward.
 No retractions or dimpling.
 No lumps or masses are
palpable.
 No tenderness upon palpation.
 No discharges from the
nipples.
Abdomen  Skin color is uniform, no Incision at the right Appendectomy
lesions. lower quadrant
 Some clients may have striae
or scar.
 No venous engorgement.
 Contour may be flat, rounded
or scapoid
 Thin clients may have visible
peristalsis.
 Aortic pulsation maybe visible
on thin clients.
 No tenderness noted.
 With smooth and consistent
tension.
 No muscles guarding.
 The liver usually can not be
 palpated in a normal adult.
However, in extremely thin but
otherwise well individuals, it
may be felt a the costal
margins.
 When the normal liver margin
is palpated, it must be smooth,
regular in contour, firm and
non-tender.
Extremities  Both extremities are equal in None
size.
 Have the same contour with
prominences of joints.
 No involuntary movements.
 No edema
 Color is even.
 Temperature is warm and
even.
 Has equal contraction and
even.
 Can perform complete range
of motion.
 No crepitus must be noted on
joints.
 Can counter act gravity and
resistance on ROM.

Cranial Nerves Assessment

Cranial Nerve Function Method Normal Findings Client’s Responses

I Olfactory Smell reception Ask client to close Client should be able Client was able to
and interpretation eyes and identify to distinguish different distinguish different
different mild aromas smells smells
such alcohol, powder
and vinegar.
II Optic Visual acuity and Ask client to read Client should be able Client has difficulty
fields newsprint and to read newsprint and reading the newsprint
determine objects determine far objects and determining far
about 20 ft. away
objects

III Oculomotor Extraocular eye Assess ocular Client should be able Client exhibits normal
movements, lid movements and pupil to exhibit normal EOM EOM and normal
elevation, papillary reaction and normal reaction of reaction of pupils to
constrictions lens pupils to light and light and
shape accommodation accommodation
IV Trochlear Downward and Ask client to move Client should be able Client was able to
inward eye eyeballs obliquely to move eyeballs move her eyeballs
movement obliquely obliquely
V Trigeminal Sensation of face, Elicit blink reflex by Client blinks whenever Client blinks whenever
scalp, cornea, and lightly touching lateral sclera is lightly sclera is lightly
oral and nasal sclera; to test touched; able to feel touched; able to feel
mucous sensation, wipe a the wisp of cotton over the wisp of cotton over
membranes. wisp of cotton over the area touched; able the area touched; able
Chewing client’s forehead for to discriminate blunt to discriminate blunt
movements of the light sensation and and sharp stimuli and sharp stimuli
jaw use alternating blunt
and sharp ends of
 safety pin to test deep
sensation

Assess skin Client is able to sense Client is able to sense

sensation as of and distinguish and distinguish
ophthalmic branch different stimuli different stimuli
above

Ask client to clench Client should be able Client is able to clench

teeth to clench teeth her teeth
VI Abducens Lateral eye Ask client to move Client should be able Client was able to
movement eyeball laterally to move eyeballs move her eyeballs
laterally laterally
VII Facial Taste on anterior Ask client to do Client should be able Client was able to
2/3 of the tongue different facial to do different facial smile, frown, raise
Facial movement, expressions such as expressions such as eyebrows, and identify
eye closure, labial smiling, frowning and smiling, frowning and different tastes
speech raising of eyebrows; raising of eyebrows;
ask client to identify able to identify
various tastes placed different tastes such as
on the tip and sides sweet, salty and bitter
of the mouth: sugar, taste
salt and coffee
VIII Acoustic Hearing and Assess client’s ability Client should be able Client has no problem
balance to hear loud and soft to hear loud and soft with hearing
spoken words; do the spoken words; able to
watch tick test hear ticking of watch
on both ears
IX Glosso- Taste on posterior Apply taste on Client should be able Client was able to
pharyngeal 1/3 of tongue, posterior tongue for to identify different identify different tastes,
pharyngeal gag identification (sugar, tastes such as sweet, able to move tongue
reflex, sensation salt and coffee); ask salty and bitter taste; from side to side and
from the eardrum client to move tongue able to move tongue up and down, swallows
and ear canal. from side to side and from side to side and without difficulty, with
Swallowing and up and down; ask up and down; able to positive gag reflex
phonation muscles client to swallow and swallow without
of the pharynx elicit gag reflex difficulty, with (+) gag
through sticking a reflex
clean tongue
depressor into client’s
mouth
X Vagus Sensation from Ask client to swallow; Client should be able Client was able to
pharynx, viscera, assess client’s to swallow without swallow without
carotid body and speech for difficulty; has absence difficulty, no
carotid sinus hoarseness of hoarseness in hoarseness in speech
speech
XI Spinal Trapezius and Ask client to shrug Client should be able Client was able to
accessory sternocledomastoid shoulders and turn to shrug shoulders and shrug shoulders and
muscle movement head from side to turn head from side to turn head from side to
side against side against resistance side against resistance
resistance from from nurse’s hands
nurse’s hands
XII Hypoglossal Tongue movement Ask client to protrude Client should be able Client was able to
for speech, sound tongue at midline, to protrude tongue at protrude tongue at
articulation and then move it side to midline and move it midline and move it
swallowing side side to side side to side
Acute Appendicitis
Nursing History and
Physical Assessment

Submitted by:

Costales, Geraldine L.

BSN III – Sec. 1, Group 2

Submitted to:

Ma’am Lea Marie S. Aquino

Ospital ng Makati – Male Surgical Ward

January 27, 2011